Docs Need Better Training to Treat Opioid Addiction, Congress Told

Medication-assisted treatment is often the most effective, witnesses said.

WASHINGTON -- Physicians need better training in how to manage pain as well as how to treat addiction to opioids, several experts told a congressional committee.

"[We need] to develop better strategies for the management of chronic pain," said Nora Volkow, MD, director of the National Institute on Drug Abuse, in Bethesda, Md., while testifying Friday at a House Energy and Commerce Oversight and Investigations Subcommittee hearing on government efforts to combat the opioid abuse epidemic. "Physicians are forced -- their patients are suffering, they don't know what to do and give an opioid, even though the evidence does not really show us they're effective for chronic pain, but there are not very many alternatives."

Michael Botticelli, director of the Office of National Drug Control Policy (ONDCP) here, noted that "since time in [graduate medical education] programs dedicated to the identification and treatment of substance use disorders is rare, we've worked with federal partners to develop continuing education programs on substance use, managing pain appropriately, and treating patients using opioids more safely .... [However], a large percentage of prescribers have not availed themselves of this training."

That is one reason why "the [Obama] administration continues to push for mandatory prescriber education tied to controlled substance licensure," he added.

In his opening statement, subcommittee chairman Tim Murphy (R-Pa.) listed the high numbers associated with substance use disorders. "While the trends of other major causes of death such as auto accidents went down, drug poisoning continued to go up 21% from 2008 to 2013. In many states these numbers are soaring at high double-digit rates of increase," he said.

"As Mr. Botticelli has indicated to me privately ... we must do better and we have much work to do."

The hearing witnesses generally agreed that medication combined with behavioral support has been shown to be the most effective treatment for substance use disorders including opioid addiction. In particular, "methadone, buprenorphine, and naltrexone, when used as part of a comprehensive addiction treatment plan, have been shown to facilitate abstinence and reduce overdoses and HIV infection," said Volkow.

"Yet despite the strong evidence, less than 40% of those receiving treatment for opioid addiction get treated with these medications."

The reasons that addicts aren't receiving evidence-based treatment are varied, said Volkow, "including the fact of adequate education as it relates to screening and management of substance use disorders, and then a whole infrastructure has developed because addiction is stigmatized, so the likelihood of people accessing care is much lower."

Richard Frank, PhD, assistant secretary for planning and evaluation at the Department of Health and Human Services, added that other reasons include "insurance dynamics that hopefully we're fixing, access to trained professionals, and then there's... trying to get the system, the infrastructures aligned so they support the best practices."

Murphy expressed caution about continued encouragement of medication-assisted therapy, in that continued reliance on opioids is a high risk factor for heroin addiction. "I have referred to buprenorphine as a 'heroin helper' not because the medication is altogether lacking, but rather, because the infrastructure the federal government has created for the use of this highly potent and important medication is not working and, worse yet, is contributing to the growing problem," he said in his opening statement.

"Again, please do not misconstrue this critique as a general indictment of opioid maintenance," he added. "It is not. For some people, opioid maintenance is the most appropriate bridge treatment and there should be no shame or stigma associated with it. But opioid maintenance therapy should not be the only treatment offered to opioid-dependent individuals, nor the only goal."

Subcommittee ranking member Diana DeGette (D-Colo.) took a different tack. "Why do we have experts week after week telling us the bulk of treatments Americans are receiving for this devastating disease are ineffective, outdated, and not evidence-based?" she asked in her opening statement. "We might not have a silver bullet ... at this point, but we do know what treatments work better than others. I think we need a multi-faceted approach."

Murphy also wanted to know more about how the witnesses defined "recovery." "[When] the ONDCP uses the term 'recovery,' does it mean to include patients with opiate addiction in buprenorphine or methadone treatment programs and still using heroin or other illicit drugs, or is that not recovery?" he asked Botticelli.

In his answer, Botticelli did not shy away from talking about his own history of substance use disorders. "From our perspective and also as a person in recovery, clearly we want to make sure people are continuing to progress in recovery and that freedom from substances is the ultimate goal," he said. "But we also know substance use and opioid use disorders are significant chronic disorders, and often, and even in my own experience, people will often experience relapse and will often need multiple attempts at treatment to get to that long-term goal."

Neonatal abstinence syndrome (NAS), which occurs when a woman takes addictive opiate drugs during pregnancy, was another problem the witnesses mentioned at the hearing. Volkow said that an article in the New England Journal of Medicine" shows a very significant quadrupling in the number of cases of NAS in the [intensive care unit]; that does reflect the fact that many women are being prescribed opioid medications during the pregnancy itself."

"Another study estimates that 21% of women who are pregnant are going to receive an opioid," she continued. "That highlights [the fact] that guidelines in management of pain need to be enforced in better ways."

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